Learning Intubation with Airtraq at the Simulation Lab at Center for MEDICS
Posted by dthomas	on April 9, 2009
Paramedic trainees need to complete 10 successful endotracheal intubations (ETIs) in an operating room (OR) for their minimum skills requirement under the Office of Emergency Medical Services (OEMS) in Massachusetts.
Yet meeting this requirement is becoming more difficult. As operating rooms are increasingly using breathing devices other than endotracheal tubes (ETTs) to support patients, trainees may have fewer opportunities to obtain the certification points they need.
In addition to the lack of opportunity for practice is the technical difficulty associated with intubating in the field. A March 2009 JEMS article looked at the success of prehospital ETT placement. The studies reviewed showed the incidence of misplacement to be anywhere from 5 percent to 9 percent, and even higher.
Despite these factors, paramedics need to become competent at ETIs for lifesaving purposes. At the Pro EMS Center for MEDICS in Cambridge, MA, this need for more sophisticated training in intubation skills is being addressed.
Under Director Chris Kerley, the Airtraq laryngoscope is now being used at the Center for MEDICS as a practical learning tool for ETIs both in classes and in the Simulation Lab. Paramedic students are able to hone the skills they learn in the classroom on lifelike human manikins.
Not only do trainees learn the technique of intubation at the Center, but they are also able to practice ETIs in a wide variety of simulated settings.
"One thing we teach is to anticipate difficult airways. A difficult airway is something to anticipate, not experience," Kerley says.
In the Simulation Lab, different cases and scenarios can be recreated, so that paramedics become familiar with, and more comfortable in, challenging situations.
Kerley is also a member of the state's Airway Committee of the OEMS, which analyzes BLS and ALS airway skills in Massachusetts, and reviews data and new equipment.
"We want to embrace new ideas and analyze the current data out there so that we are taking an evidence-based approach to airway management," he says.
In addition to using Airtraq in their training center, Pro EMS is training their staff to use this laryngoscope in the field. All paramedics in the Cambridge EMS system – including Pro EMS and the Cambridge Fire Department – will soon use the Airtraq for ETIs.
Kerley believes that Pro EMS is one of the first services on the East Coast to use the Airtraq. Describing the new laryngoscope, he says,
"It's the first disposable device of its kind on the market. That's why we like it. You just use it once, and then dispose of it." He cites its lower cost as an added benefit.
The Cambridge EMS system performs about 120 ETIs a year; numbers for the state of Massachusetts have not been available in the past. As part of its new regulatory requirements, however, the state will begin collecting and analyzing this data, Kerley says.
Becoming adept at performing ETIs takes practice. While learning to place an ETT in a controlled, operating room environment with an unconscious patient on a waist-high stretcher is helpful, it does not reflect the reality of placing an ETT in an emergency setting.
Many conditions make intubating in the field challenging for paramedics. Patients are often in positions that make airway access difficult; they may be lying on the ground or cramped in a tight space. Tubes that are placed can become dislodged while moving a patient onto a stretcher or into the ambulance. Intubating in a moving ambulance presents additional challenges.
Patients may need to be intubated for a variety of reasons, including cardiac or respiratory arrest. Patients who cannot protect their airway, for example, or those who have lost their gag reflex due to a stroke, will need an ETT as well.
Improperly performed intubations can lead to a host of complications. If the ETT enters the esophagus, the patient will be inadequately ventilated. An endobronchial intubation could result in barotrauma to the intubated lung. Laryngeal and other soft tissue swelling or trauma may also occur.
In addition to reducing cross-contamination, the Airtraq has other benefits. Using a conventional laryngoscope often requires paramedics to move a patient's head and hyperextend the neck – a maneuver that can be dangerous when the patient has an unstable cervical spine. In contrast, the Airtraq requires minimal repositioning of the head. It can also be used to intubate patients who are in a sitting position.
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